“I must single out Jhpiego for appreciation…”

December 12, 2012

Mrs. Anuradha Gupta

Additional Secretary and Mission Director of National Rural Health MissionMinistry of Health and Family Welfare, India,speaking at the National Review Meeting on Family Planning, New Delhi, Nov. 1-2, 2012.

Very good afternoon to all of you and I’m extremely pleased to be here and I’m very happy that these interactions are now happening very regularly, much more frequently…you know, there is a dialogue which is going on. Diverse stakeholders are present here. In fact the attendance here is so impressive and I’m sure that you have had extremely stimulating discussions. But, I would like to really emphasize that now we are looking at very concrete action, actually action with a sense of urgency.

History of Family Planning

“I must concede, and all of you are aware that family planning was something that just got lost and derailed in India for a very, very long time after the late ‘70s. It wasn’t talked about at all, and clearly there wasn’t any focus. I think the whole situation changed, you know, under the leadership of the present Union Health Minister because as a leader he started talking of Family Planning very openly, without any fear, without any hesitation and really brought, I think, the whole subject of family planning into public discourse, even bringing that up in parliament. And I think that indeed was the turning point.

But my own sense is that at that level, they can only tell you a vision, give you a vision, but it is also important to execute that vision. I think somewhere that also didn’t happen for a long time despite the fact that there was a very keen desire on the part of the minister to really see some action on the ground. I think you know, health is so overwhelming, it is so complex and all the time we are talking about so many things that sometimes you end up getting caught in a vortex of things with a lot of important issues not getting adequate attention. I think, that indeed was the fate of family planning also. But I’m extremely glad that now we are pretty much clear on what is it that we want to do; there is a very, very clear action plan that we have formulated. I am extremely convinced and committed actually to this vision and now, we don’t want to lose our way again or we don’t want to lose steam.

A lot of you would have probably heard me talk on this subject earlier also but I would just, even at the cost of repetition, say a few things.

Family Planning as a Health Issue

One is, and I think that is a remarkable shift in our position—that we are for the first time looking at family planning not as a population stabilization issue at all. We are looking on family planning as a central component of our entire RMNCH+A strategy. We are looking at it as a health issue, as an issue which is so important, and so critical and so vital to the health of our women and our children. And I know that internationally, people have been talking about this whole continuum of care approach and RMNCH. In fact I thought that adolescent health was missing. I am no doctor or no expert but when I look at the program with a fresh pair of eyes… and I think this was something external…, because somebody coming from outside can very quickly see the missing pieces. I think that is what happened and my first question was where are the adolescents, because when the doctors sat me down to tell me the more technical aspects of their strategy and the lifecycle approach, my innocent question to them was –what is it that we are doing for adolescent health. And I really thought that adolescent health was not just a weak, but an entirely missing pillar of our Reproductive and Child Health strategy. Therefore, I represent India on PMNCH board, and I have now raised it very vigorously that RMNCH should actually be RMNCH+A strategy and for the first time I am so glad when I looked at the documents for the Manila meeting, I indeed saw RMNCH+A, which is so heartening because now I think the continuum is complete and the loop is complete and we are looking at adolescents as well.

Family Planning as Core Strategy in Maternal-Newborn-Child Health

So, if you really are committed to this whole vision of RMNCHA, I think you can’t lose sight of the immense value of family planning as a core strategy in the context of RMNCHA. SO, to us now, to me personally, family planning is that…it is now a strategy to improve the health of our women and our children and that is how we are going to view it and position it. SO therefore, you have seen that the IEC campaign that we have developed after a long lull but with the help of development partners, and I want to thank you so very much for the very good support that you’ve provided to us in developing that IEC material – PSI, USAID supported IHBP..that’s tremendous. And we have indeed positioned our message as one where the families understand that family planning indeed is beneficial to families because it protects the lives or improves the health of the young mothers, the wives of the husbands, and of course the children. So I just wanted to clarify that this is how now we view family planning.

Family Planning and Universal Health Coverage

Second of course is the importance of family planning as a part of this whole endeavour or march towards the universal health coverage. India is also talking of universal health coverage. Under the mission (NRHM) anyway, we were talking of service guarantees, very comprehensive service guarantees and I really think that universal health coverage is something which is going to unfold gradually. It is not something which is going to be achieved overnight. It is going to be attained only incrementally and I think, some of the things with which we really want to start with a bang is family planning. It is something I think that we have to stand committed to this whole vision and this whole promise of making sure that every couple in the reproductive age group gets information gets service and gets supplies so far as family planning is concerned. This is not to say that we have to exclude the adolescents who may be sexually active and would actually be seeking access to family planning services and commodities. SO it is for them, but I am just saying that at every nook and corner of this vast and diverse country, we have to make sure that we have no unmet need, we bring it down and we make sure that people are able to access all three parts i.e. Information, supplies and services.

Focus on National Strategy, Not Pilots

Now, that is a tall order. That is indeed, a very huge challenge. But here I want to say I personally believe that it is not unachievable at all. I think if we are very clear about what we want to do, what is the direction in which we have to move, I think it will take ups probably two to three years but I don’t think it is going to take us beyond that. But the only thing is that we have to stay focused on the strategy that we now have in mind. Now in his context, I also want to say, and please don’t misunderstand me, but I really want to emphasise that when we are talking of 1.2 billion population, we are looking at a nation of 1.21 billion population and within this population, you are looking at 40 crore (400 million) young men and women in reproductive age group. When we say 20 crore couples in reproductive age group, you are looking at 40 crore men and women, and of course, you have adolescents in addition to that. So, clearly it is a very, very big number and given this whole canvas I don’t don’t think now we have time or we have the patience to talk about any pilots. I am very clear on that.

We have been having pilots for god knows how many decades now—some pilot here, some pilot there. In the name of evidence, if we continue with these pilots in some areas—that’s not going to work for this huge country. So, please, as far as I am concerned, I am making my position very clear that we are not in favour of any pilots, and therefore, we are not in favour of any district based projects. And therefore my appeal to all the development partners is that resources are scarce everywhere…also you know the kind of domestic funding we have under the mission, it is really huge.

I’m not saying it is unlimited. I am also not saying that it is sufficient, considering the huge challenge that faces us, but, at the moment it is considerable, and it is rising and on family planning alone, we will be spending at least 2 billion US dollars in the next eight years, by 2020. I’m sorry I did not give this figure in the London summit and I really regret it. There, when they were talking of the global aid that was committed at London summit, it was barely 2 billion dollars but in India, in the next 5 years you are looking at more than 1 billion dollars because yearly our budget at this level is 1000 crores, so in the next 5 years we are spending 5000 crores and this is at this level.

Now that clearly we are expanding our interventions, our strategies, and giving more and more money. So, I am saying at least 2 billion dollars (in the next 8 years). So, this is just to put things in perspective. So clearly what development partners bring on the table is a very small amount but we value it, we really value it because it is so important to us because it is catalytic. Right! So it is not really the quantum of funds but it is the quality of technical support that you provide to us with that funding which can make such a huge difference.

Technical Support from Partners

So, I must tell you friends that we deeply appreciate your willingness and your ability to work with us and to provide to us that catalytic support. But in the same breath I also want to tell you that you also need to re-evaluate your whole strategy of working in the districts independently because we have seen—now if we are talking of evidence, I have no hesitation in saying that if you were to look at the evidence of the kind of experiments that have been done in the states and districts, at least I don’t see much of returns on investments which have been made.

For instance, Uttar Pradesh is a case in point. For more than two decades now people have been working in that state and I’m sorry to see when, you have the AHS data before you, and you find in UP what has changed? What has changed dramatically? Certain things would change naturally, automatically in course of time, but what is it that has changed dramatically where we say with a lot of confidence that people have made a difference, organisations have made a difference, the state government’s endeavours have made a difference? No. Because AHS data clearly tells you that Uttar Pradesh remains one state where the unmet need is the highest, where CPR (Contraceptive Prevalence Rate) is the lowest, where TFR is the highest—and I think it’s a very sorry state of affairs. And UP is also somewhere, where there was a lot of focused effort at FP.

National Strategy and State Governments

I think it is time to sit back and now with a very open mind make some honest candid admissions and say, OK, this hasn’t worked but why it hasn’t worked. And my whole (point) is that let us not now have strategies which have no clarity, or which are ambiguous or where we are trying to learn what are the patterns of need or what are the methods which are preferred by people. We know by now, we really know by now; and at the national level once we have this whole clarity on strategy, I think, every one of us including all development partners, including the faculty which is here from medical colleges and of course, the civil society representatives– all of us have to then get committed to that national strategy and say we are going to do our bit in order to make sure that this is realised and implemented well and therefore, you know, my request to you is that whatever resources you have or whatever capacities you have, they have to utilised to work with us at the national level because it is the national nerve centre that you need to strengthen now so that at the national level we can monitor much more effectively what is happening on the ground—in states where the TFR is still the highest. And not just monitor, we can also mentor.

And also, when we have to go to the states like UP, Bihar, Jharkhand, or Madhya Pradesh, Rajasthan, I think we need to work with the state government because I know that the state mission the resources are expanding but the capacities are very weak. I think the mission director there actually needs help by way of top quality technical resource, who can go out in the field, who can work with the district heads or the family planning program officers; see what ASHA is doing, what ANM is doing; whether information is getting disseminated or not and things like this.

Understand the Vision, Praise for Jhpiego

But, personally, I am not in favour of any resource being deployed at a district level because I think national level and state level you just strengthen and people can move around, and I think we really need to work towards unity of command—where people are working are actually connected with the national program division so that all of us are completely aligned in our effort, our efforts are harmonised and they are strengthened. And people are not just working in their own direction in isolation. So, this is going to be of critical importance and really I must single out Jhpiego again – I’m sorry I can’t help it – for appreciation because I personally feel, you know the one thing that we said –we said look PPIUCD…and they’ve just worked. I have personally seen how in a focused manner we are able to take this forward. So just a broad point that let us all first understand the vision, let us all get committed to the vision and then let us all join hands to realise that vision by way of a harmonised strategy which is actually where mentoring and monitoring is done at 2 levels- at the national level and the state level.

I would be very happy to interact with you on this later, I don’t think today we’ll have time. Think about this and we can meet again but that would be my appeal to you.

National Strategy Highlights

Now, so far as the strategy is concerned—what is the strategy? Now, you know, I think Sikdar has spoken about it. I spoke at the London summit. I’m going to simply put it. So, the first highlight of strategy is for the first time, very emphatically, without any confusion, without any ambiguity, we are saying that spacing is our focus. I keep joking and was telling Sikdar at IHBP— you want to be politically correct. He always wanted to say equal emphasis on spacing and limiting. That doesn’t happen. So family planning was somewhere falling between 2 stools of spacing and limiting. He was wanting to do both, he wasn’t able to do either. So, therefore, you have your sterilization figures stagnating at 50 lakhs a year. When you desegregate it you would find a lot of them happening after the third child or the fourth child. So Sikdar sitting here may feel very happy that we have done 50 lakh sterilisation, but what impact those sterilizations have is anybody’s guess. It varies from state to state but I’m just flagging an issue. And also, I think there are other challenges and the other challenges are—one is that you have a shrinking pool of providers within the public health system. Because when you’re talking of laparoscopic surgeries, then gynacs are not doing it, largely, it is the surgeons and you need surgeons and you need surgeons for other high quality, high value added surgeries and they are also shrinking in the public health system and why should a surgeon only be doing laparoscopic surgeries—that is when you’re also looking at power shifting.

People are now coming to public health institutions for a variety of high end treatments. Also, we are not being able to recruit surgeons. So, one is, with this limited pool of service providers, what is the extent to which you can scale up the sterilizations, that is one. Second is, I don’t know for whatever reason, minilap trainings haven’t worked. States haven’t got enthused on minilap trainings, so MBBS doctors haven’t got trained in adequate numbers, so it hasn’t worked. ….Dr. Sikdar also has to take into account the political climate, the political sentiment, and you know, not upset people by taking some position. But what happened, I’ll tell you how it happened.

Teenage Pregnancies

One day when this SRS report came in, I pulled it out and I was just going through data, and this is one figure which nobody talked about but which really struck me like a bolt and this was this 45% of our maternal deaths in the age group of 15-25. Believe you me, that is the time when I came back to office, asked Sikdar “Sikdar have you seen this figure? Is that a fact?” And then if you read it along with the other data which is 47% of fertility in 15-25 age group, 45% of maternal deaths in the age group of 15-25; the 5.6% of teenage girls becoming mothers or already mothers. Then EHS data now, which again he presented a lot of data, but I would single out just one data which is very interesting to me. That out of 284 districts which were surveyed, in 85% districts, 35% are teenage pregnancies. Now that is shocking. And I told them – you tell me, it doesn’t make sense to me 5.6% teenage population becoming (pregnancies). So I said, you tell me, in a year we have 3 crore pregnancies—tell me how many of them are teenage mothers. And they really had to go back to the drawing board. I think, he (DR. Sikdar) did some exercise, some jugglery, but he gave me a figure of 32 lakhs teenage pregnancies per year…

I really think we need to look at this data otherwise we’ll go wrong in our program. So, 32 lakh teenage pregnancies—what does that mean? It really means that more than 10% of the pregnant women each year are actually teenage girls. So, therefore, what is it that they need? I didn’t need to be a doctor to understand that what they need is not sterilization, what they need really is spacing. And therefore we just made up our mind and I said we don’t have to take directions or instructions from anywhere, and to me this is evidence based policy. So one (point) is that there is unambiguous, very clear, evidence based focus on spacing now. We are not saying that sterilizations are going to be derailed because I also want to say that I don’t know what the international perception is about sterilizations, but I think in a country like India, sterilizations are also among a preferred way of limiting your family because for a lot of women probably that is convenient.

Quality Services in Public Institutions

See as a working educated woman, I may not like going to for sterilization. But a poor woman, she may not like to go in for IUCD and she may like to sterilization, if she feels good about it. So, we can’t really say that it is a question of either or. But what I am saying is so far as sterilization is concerned, we are going to make sure that quality services continue to be available in public health system to who those women who actually are desirous of this option because after all, it is about choices. So that is a choice which has to remain available. But that choice is there so I think we really need to work on quality aspects and see that these services are there. When we talk of sterilizations, I also see a role being played by the private sector because given our capacity to do sterilizations, I think that is where private sector can actually step in.

So therefore, one prong of our strategy is really going to be to encourage states to empanel private sector providers because that hasn’t happened to the desired extent and see that they also become a part of this whole strategy to cater to the demand for sterilization. But while that is a prong of our strategy, I don’t want that to cloud the better part of my strategy.

Birth Spacing and ASHAs

So, then what is the better part of my strategy, and the most important part of my strategy where we didn’t even get started and that is spacing. Therefore, I think spacing is something that we are putting on the table, bang there, and saying this is where we’re putting our money on. And in spacing, there are three things that we are doing. One is that there has to be a doorstep distribution of contraceptives by ASHA. That is something, I personally feel very convinced about. This was done in 233 districts. I didn’t get rolled out in UP till the very last. But wherever it was rolled out, and we got three independent evaluations and I don’t know whether Sikdar has shared that with us, we found the results very encouraging– 95% of women feeling very happy; ASHAs feeling very empowered; ASHAs using it as an entry point into the household for a variety of health messages; and in many cases ASHAs even being able to establish a rapport or communication with the husband. SO therefore, I think that is what we want, and ASHAs very willing to take up this thing. SO, once we have this huge…I also think that the beauty lies now in leveraging the assets that we have created and I think, the one singular achievement of the mission is the collusion of this huge workforce an army of 8.6 lakh ASHAs.

Now, that’s not a small number. So, how do we leverage them? If we have these foot soldiers on the ground, why should we not use them? We must use them. I know in those countries where you don’t have people on the ground in such large numbers, this may not be workable, but in a country like India where we are looking at a large number of clients, 80% of who are actually in rural areas, many of them in remote and inaccessible areas, and you have ASHAs who are catering to 1000 population—they anyway are supposed to establish contact with the population which falls in their charge, what is the problem, there is no problem at all. So therefore, now we have decided to scale it up to the entire country.

So that is what I mean by pilot. We did it for a year 233 districts and this year we are saying, universally across, whether high TFR or low TFR or whatever, ASHA…. Otherwise we are pumping a lot of… India is one country where we are self-reliant in terms of production of FP commodities and we are pumping in so much of contraceptives. However, I am not sure where they are lying and whether people really had access to them. So, I really feel that..at least I didn’t see them anywhere in any of the facilities. So I think that it is important that ASHA gets the contraceptives, ASHA takes them to the doorstep and I think that is true access because then you make sure, that if people want to have, people want to buy a pill or condom or even e-pill wherever they are needed, I think that’s available. SO, availability is ensured universally. So, that is one. And now Urban Health mission has now been cleared by EFC, we are going to the cabinet. So, my hope is that we’ll be able to roll it out soon so urban areas will also have coverage. So, really universal coverage where ASHAs are going from house to house and delivering certain kinds of contraceptives.

Auxiliary Nurse Midwives and IUCDs

Now, the second prong of this strategy is again there…I again thought as a student of management, should I rely on a couple of thousands of my service providers or should I look at my two lakh ANMs and see how can we leverage. After all, like our ASHAs, we have 2 lakh ANMs. Now what do we do with them? How many countries have armies like this! So if India has an army of 2 lakh ANMs, why should we not leverage them? And she (ANM) is primarily an RCH (Reproductive and Child Health) functionary. And she can very easily insert IUCD. There is no dispute on that or debate on that. So why and how is it so difficult or impossible for us to train these ANMs! SO, if we really put our mind to it, get determined, we will train all our ANMs in sub-centres, to insert IUCDs and then followed by…if you train them and they don’t provide (services) they lose their skills, this has happened in the past…but followed by a regime where we are saying that every sub-centre would offer IUCD services at least 2 fixed days a week, and believe you me, I am really going to make it every day because now you have to view these strategies in the context of a much larger picture that is emerging.

Now separately, we are wanting to strengthen our sub-centres with 2 ANMs, one multipurpose health worker, one community health officer, one LT. I don’t think HR would be available in one go in all the states but that is the direction in which we have to move because we have more money now and we want to strengthen our sub-centres. If that happens, our insistence also is that the sub-centre must remain open every day, one of the ANMs must do outreach, one of the …wherever we have two ANMs and in a large number of states we have 2 ANMS in the (subcentres) and we are saying that one of the ANMs should move to the filed, one should remain at the sub-centre, the sub-centre should remain open. That is the direction in which we want to move. And if the sub centre remains open and your ANM is trained in inserting IUCDs, I don’t foresee any difficulty as to why IUCD insertion should not be done every day. But the port of call for women who want access to IUCD services is of course the sub-centre where ANM is trained.

High Case Load Facilities

Now, the third prong of this strategy is looking at high case load facilities. JSY brought in 1 crore 20 lakh women , (which) is not a small number, delivering in public health institutions. I think it’s a huge opportunity that we should encash. And then JSSK where we are giving free entitlements now to everybody is going to further push this number. So now I won’t be surprised in another one year we actually touch about 1.35 crore women actually delivering in public health institutions. And also separately we have done this exercise of mapping those facilities….after all 2 lakh facilities are not handling deliveries. So when we sat down and we said how many of them actually have respectable case loads of deliveries, we found they are 16000. They could go up to 18000, they could go up to 20,000, but 20,000 facilities where women in large numbers are delivering—why can’t we train our service providers there for PPIUCD. So, its not such a number.

So my request to everybody whose sitting in this room is please join us in this endeavour. There is now no confusion, there are no gaps in this vision at all. If you have any questions, in fact I would like to take them because I say that on 20,000 facilities PPIUCD services are not a problem and that is why when Jhpiego designed this whole thing, and I couldn’t speak to Bulbul directly but I did tell Sikdar and Dr. Sushma, I said I am not in favour of doctors getting trained in PPIUCD. There doctors do not go and put IUCDs. I am sorry to say that, they don’t do deliveries unless it’s a C-section. Normal deliveries are handled only by nurses, and therefore, whoever is actually doing the delivery who is in the labour room is going to do the PPIUCD. SO, let us get realistic on this.

‘Let’s Get Realistic’

And really my imploration to everybody—let us not talk of rhetoric, or things which have worked here or there. Let’s get realistic. We all are aware of the Indian picture and the Indian health landscape. You all have been to facilities; we all know what the truth is. So when we know that the doctors don’t do it, why are we wasting our resource on doctors! You train you nurses, you empower them and they will put PPIUCDs, and who will motivate them—the counsellors. But my vision would be to take them to all high case load facilities and here you know how we’ve integrated…I’m saying though we started with FP, we are saying they are RMNCH counsellors. What a wonderful job in developing a TOR which is so comprehensive and my compliments to Dr. Sikdar (who) I think has really worked very hard. Those jokes apart, I think he has really worked extremely hard on all these things and the single-minded devotion he and his entire team has worked on this.

So, now we have started, Bihar has started appointing counsellors, and I believe they are high quality people. So, therefore, you start training them in these TORs and we make sure that it is counselling is done. SO RMNCH, whether it is breastfeeding or other childcare practices or whatever the counsellors who are positioned there, I am prepared to increase their numbers. I know that there are facilities where 1000 deliveries are taking place and with a single counsellor we can’t do. In fact, our endeavour would be in these selected facilities 24X7 counselling should be available. That’s my vision and we are prepared to give money. SO that is why I said 2 billion at least…it can go really up you know if we look at all this HR and all. The point is that no matter what time a woman delivers in a facility, PPIUCD, if she is willing, must be put. And second is no matter when she gets admitted there should be a counsellor to counsel it.

Incentivization

The fourth of course is…you know now there is this whole issue of incentivization. I also want to put the record straight on this. Because one is this ASHA thing. ASHA we must appreciate because we did this…we took a proposal and the mission steering group approved it…Rs 500 we said if the birth is delayed.. if the first birth is delayed after marriage, we said, then she gets Rs 500. Why not, the first birth should be delayed..we are very happy that the mean age of marriage has risen to 21. It used to be 20 point something. So it has shown an improvement but you know if you desegregate data you would find a across states..in Rajasthan the number of girls who are getting married before 18 years of age is huge so therefore, delaying… giving this message that you should delay the first child is a very good message and if ASHA succeeds in taking this message why should we not incentivise her!

We should also understand that ASHA is not a salaried employee. We only pay her performance related incentives. It’s not just for family planning, it’s also for ANC check-up, for institutional delivery, for following up a low birth weight baby, for home based new-born care…for a whole lot of activities. SO why should she do FP without any incentive when all that she’s getting is incentive based remunerations. So, you have to view these incentives in that context.

And then we said the first and the second child again she will get Rs 500 because if 47% of your births spacing is less than 30 months, so therefore, if that is the case in India, should you not take the message to the families that they have to have a gap of three years between the first and the second child! And if the ASHA takes that message would she not expect an incentive that she gets for a variety of activities. SO that is what we said. And for sterilisation, we said that after 2 births if she puts a permanent stop anyway you are giving money Rs 150 to any motivator, but ASHA who is doing so much of work, who is taking home so little. So, if you give her more money and say that ….so I just heard those rumbles and those people saying oooh this incentive…I think we should shun this whole thing. Because there is a certain cultural context to this country, right, and I think the need graph or the need pattern of the any country, it can’t be alike. I mean in the US, what a woman needs is not the same as what a women in rural India would need. So therefore we need to appreciate those cultural differences in terms of need, in terms of …

Cultural Differences

In the US today, if a woman decides to have a contraceptive, husband cannot stop it. She can go to any health facility and access any method that she prefers. In India, when a woman wants to control her fertility, she doesn’t have that freedom because the husband would batter her up. Also she doesn’t have the wherewithal to go upto your district hospital and things like this. So someone has to take the service to her doorstep. So I mean, earlier we used to be blamed that in India we have this one size fits all approach where we used to design a program and we used to just push it down the states and say that this is the best way of doing it, do it like this. We have learnt our lessons and therefore, under the Mission we are saying, we are not going to tell you what is best for you but you tell us what is your need. For instance, our strategy is very clear but if some state like Uttarakhand wants to stand up and say look we want to just tweak and we want to tweak it because of this reason, we are open to that. So this whole thinking (that) incentives are bad for Family Planning, reproductive rights are taken away, there is violation, there is coercion—I don’t know what we are talking about. And it does annoy me a lot.

So, I am just saying that people who don’t understand the program a lot, they must first try and understand how the program is functioning, what is the role of ASHA, what kind of incentive does she get etc. etc. before making these very very sweeping statements. We must also understand that we are giving cash assistance not just for FP. Look at Janani Suraksha Yojana… we are giving Rs 1400. Now any number of people have come up to us and told us – look if you give Rs 1400 then women are motivated to produce more. I really don’t believe it. I think we are discrediting completely the intelligence of an Indian woman that she would produce a child only because she gets Rs 1400. Yesterday in the state health minister’s meeting also one or 2 ministers said – look, in these high focus states you give Rs 1400 to every woman regardless of the parity, and so people who think government is incentiving.

Sorry, I think these are people who don’t understand the grassroot reality because the reality is the woman does not have control over her fertility. She has to produce more and more every year and therefore, she is the woman whose life is really at risk and danger. And therefore we are saying please for God’s sake don’t deliver at home, come to our institution so that we can better care of you and your child. And some people said this… and I think ministers bring with them a certain understanding of issues because they deal with people … they didn’t say that you take away Rs 1400. They said that look this is an issue, but you make FP compensation Rs 2000, not Rs 600 but Rs 2000. Now I know that here in this room there are lot of people who will say that if we do Rs 2000 they will say India has taken away reproductive rights, and have distorted the choices and have gone in for coercion. Sorry, it is not like that.

A Voluntary Program

We are not coercing, it is a voluntary program. You have seen that nobody is being forcibly taken. We are only committed to one this thing. We will provide services, we will provide information, we will provide commodities, and that’s about all and let people take their own decision. We would do IEC, we would educate them on the benefits of small family, that’s all that we are saying. But, in this country, cash transfers work. Why is it that for a delivery cash transfer can work but for FP cash transfer is blasphemy, why? For bringing the child to a school, we want to give a cash reward, for immunization someone said we should give cash…for everything…then why is except FP.

So, I’m just leaving this thought to you that for everything else for cash transfer nobody says its coercive, for FP why people say that it is coercive?

Appeal to Development Partners, Jhpiego Praised

So my request to all the development partners is now, that this is the strategy that I have unfolded to you, which I’m sure even Dr. Sikdar and all have also talked about is the strategy which is the country strategy, and my request to you is to stop talking about any other experiment and pilot because we would not support it. And I will be extremely grateful to everybody who wishes to partner with us. You treat this national strategy as the IT backbone and you can all plug into that. You really need to get onto this national vision that we have and work with us because we don’t have the capacity, we really value your technical support, your technical capacity, what you bring to the table. And we need that so please work with us. Jhpiego has worked with us, is working very well, that is why I said, PPIUCD (which is) a part of our strategy, Jhpiego is willingly there and doing it with..and I am very happy personally.

So therefore I would like all other partners to just understand. That’s why I have taken time again to repeat this whole vision that please work with us to make sure that whatever money you are spending, whatever resource that get aligned- either that works with us at the national level or at the state level but not beyond that. Otherwise there is no accountability. We are now pumping money, we are demanding more accountability from states, right. So I would request you to join us in order to enforce accountability because money can’t just flow to the states without results. We are talking of results, we want certain concrete outcomes, and we need the partners help in this. So that’s about all and I look forward to some very very fruitful collaboration with all of you. Thank you!!